Introduction :
Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education. Each month we publish a case and link a paper with associated questions for discussion. Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field.
The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post! Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience. We look forward to hearing from you.
Title : “Pointing Fingers”
The Article :
Additional Reading & Podcast for those interested in a deep dive :
http://revisionisthistory.com/episodes/26-the-hug-heard-round-the-world
The Case :
“I think it’s important that we highlight this is a debrief, not a chance to point fingers.”.
Nimali paused and took a deep breath. Debriefing a traumatic event (particularly the sudden murder of a reviled colleague) had exposed frames that were more tribal than she’d anticipated. Within this small group of people the frames were legion. She glanced nervously across at Nitin, grateful that his calming, loving presence was within reach across the circle from her.
“What else are we supposed to do, Nimali?” Jess snapped angrily. “We know full well that one of us murdered him. And let’s face it, some people here have a clear motive.”. Jess’ usually unflappable emergency nurse façade dropped for a moment. “Everyone in PICU hated Snythe, especially you Brad. Didn’t you once tell him that his primary source of hydration was the carbonated tears of bullied interns?”.
Brad choked on his coffee and coughed frantically as he formed a counterpoint. “I did hate Snythe.” He admitted. “But truth be told in a high stakes environment like children’s ICU, there’s lots of strong personalities I don’t always warm up to. We have to be hard. We see too many children die to be cuddly. He was a cynic, but so am I in some ways… I respected him. He was a good intensivist, he was just a pretty nasty person. I’d trust Snythe if my child was on inotropes, no questions.”.
Catherine gave a wry half smile, “I’m glad you could see the good in him, his behaviour in ED left him few friends. His brand of hierarchical bullshit didn’t go down well when we called him for help.”.
Jacob frowned. “I guess I didn’t know Snythe as much as an Intensivist, I knew him as an educator. And in the last 12 months he’d grown into a much more open person. The same vicious sarcasm he had on the ward would sometimes be disarmingly funny when we were teaching new grads together. He’d even applied to be director of education a few weeks ago… He asked me for a reference.”.
Jess glanced at Brad again. “Didn’t you apply for that job?”.
A heavy silence hung for a few seconds in the room when suddenly the lights blacked out and the room descended into darkness. Nimali jumped as her phone began to ring frantically with missed call notifications.
Her iPhone lit up in the darkness :
Discussion :
Last month in journal club, we explored teamwork behaviours through an ethnographic lens. This month we want to extend that conversation by exploring other in depth theories regarding barriers to effective team formation. In this month’s open access article, Bochatay et al explore the way we filter the messages we receive from other people by their hierarchical position and social group. For those among you who are deep divers, we’ve also attached a podcast and additional editorial with similar themes.
We look forward to the discussion!
References :
http://revisionisthistory.com/episodes/26-the-hug-heard-round-the-world
Hello Jesse and Ben,
I am glad that one of the tenets of this site is to have online psychological safety.
I first read the Bochatay et al. article, then Eppich & Schmutz’ commentary. I found the social identity theory discussion useful in giving a terminology to the in-group/out-group behaviors that I have observed in healthcare. I appreciated the four strategies outlined in the commentary, and am glad that Walter and Jan provided suggestions for transforming some of these potentially challenging conversations into productive learning opportunities.
I decided to delve a little deeper by listening to the podcast. I was not sure at first that it would resonate with me – until I experience a huge “aha” moment. A few months ago, I heard a simulation colleague advocate that it would be good to refer to people in the third person, or by their titles, during debriefing – rather than call them by name. Their rationale was that it could neutralize negative emotions. I disagreed, and expressed my concern that calling someone “the nurse” could be perceived as very impersonal and hierarchical – especially if done by a physician debriefer. The speaker did not agree with me, and said that the nurses they worked with all liked this model. I still had my doubts, and internally wondered if those nurses were just too afraid to speak up against the hierarchy. When I heard Malcolm Gladwell quote Malcolm X in describing the difference between the house negro and the field negro – it struck that same nerve.
When we look at social identity theory to understand the reasons for the in-group and out-group behavior, it gives us a way to discuss the behaviors and barriers that create the house nurse/woman/LGBTQ/etc. paradigm. (I hesitated to write that last sentence, as it did not seem “politically correct”. However, it also seemed correct to call out the fact that our culture/system can create such divisiveness). How wonderful that Walter, Jan, and others are exploring and explicating ways to break down those barriers and behaviors. I am profoundly grateful that in my own professional career – I found my kindred spirits across professions, gender, and other perceived boundaries, before encountering too many of the in-group architects.
Hi Susan it’s so nice to have you back with us this month! I agree with you strongly with regards to the referring to colleagues by position reads as dehumanising rather than Emotionally neutral.
I’m glad you enjoyed the additional deep dive reading and the podcast. To me they all very much hit at their heart about what it means to belong, how important that is to us as a driver of our behaviours, and it helps me be wary of this in myself but also hopefully reminds me to try and be more empathetic when I see it in others. I don’t always succeed I guess, I like belonging too.
I am rather fascinated by qualitative research papers – trying to take on the lens of a new theory like social identity theory is like reading a juicy new novel… so I was sucked in to this story – and could identify with the examples. Intersectionality was a useful concept to describe the complexity of how our membership of different groups (eg gender and role in the hospital) interact. It rang true to me that hierarchy is the most salient social category involved in physician conflicts. It seemed an ironic fact that during conflicts with out-groups, we emphasise the positive behaviours of our in-group colleagues and criticise out-group colleagues. It made sense that conflicts between groups have negative effects on group interactions and hardens the boundaries separating groups.
Junior doctors are under enormous stress trying to fit in to their in-group, and become knowledgeable members of that specialty… and since many rotate every couple of months they are always working to fit into a new In-group. The actions of those higher in the hierarchy may have greater consequences than they realise. It is easy for conflicts to occur – and the junior doctor may not be in a position to use this “moment of tension” for a “productive conversation”.
As a supervisor of junior doctors (and still in training myself), this article helped me reflect on my responsibility to help my colleagues feel welcome on my team and reminded me of some simple tools to minimise conflicts; being careful of the consequences of my actions, explicitly welcoming input, thanking team members, and modelling perspective taking – explaining how I might understand the sometimes annoying actions of an out-group member.
And Eppich’s editorial gave me a moment of relief thinking about how to make productive use of conflict when it inevitably occurs. A conflict could turn into a great teaching moment if I can model an inclusive, productive and ethical approach.
Lots of things there to look forward to on my next shift ?
The Mater Sim Team Curry Journal Club met again over a delicious meal (with our special guest Ben Symon) to discuss this month’s paper by Bochatay et al.
The strengths of the paper:
• We found the application of the social identity theory within the healthcare setting to be very interesting. To group members newly exposed to the theory it struck a chord on both a personal and professional level. The innate sense of belonging to a group and how this impacts on behaviours and group interactions were clearly outlined by the authors.
• Methods were well described and as novices to qualitative research we gained much insight to how one might do this work well (not that we were able to judge – just assuming).
Other points discussed/raised:
• There was some confusion over the term ‘group processes’: was this the interaction between in-groups and out-groups, where conflict was experienced as a result of poor relationships, how to perform tasks or from organisational processes? Our discussions failed to gain further clarity.
• We were left pondering what additional educational strategies could be employed, other than those offered of inclusive leadership / teamwork and perspective taking. Whilst highlighting important points and a timely reminder of maintaining the basic assumption of ourselves and others we felt that we needed a ‘deeper dive’ read of Eppich’s and Schmutz’s paper for greater learning from the teamwork strategies that they suggest.
• We considered how social identity theory could impact upon our simulation debriefings. Conversely to what was suggested in the paper regarding holding positive regard for our in-group, some of the sim group wondered whether during interprofessional debriefings, we had subconsciously taken a more favourable stance towards participants of out-groups than to those of our own professional group. We contemplated if this resulted from setting higher expectations of our own in-group or an example of intersectionality (or indeed tokenism as put forward by Malcolm Gladwell’s Revisionist history podcast) within healthcare.
Thanks for joining us at dinner Ben and thanks to the Simulcast team for more providing interesting reading and discussion.
Hi Sue, thankyou so much for your wonderful summary of a lovely, aromatic discussion.
It was great to join you all at curry club, and I am so grateful for the support and the groups critique of the paper.
At first I wondered what I would make of a paper based on “social identity theory”. A theory I hadn’t heard before and thought might be very abstract and lack application. However as an anaesthetist working in the OR I realized I live this reality everyday from my days as a trainee to a senior consultant! The paper by Bochatay in its exploration of intra and inter group conflict revealed common experiences that unfortunately resonate with us all in the health professions. They assert that conflict involving group processes led to decreased confidence, disillusionment and increased negative perceptions of out-groups. Certainly this rings true but they don’t really provide data to support this? Certainly I have witnessed all of these.
After so much data collection and analysis the discussion regarding minimizing conflict seemed a little brief. Valuing contributions and perspective taking are certainly valuable but isn’t there more? The Eppich/Schmutz commentary helps complete this discussion. Their discussion of perspective taking, inclusive leadership (includes valuing contributions), team reflection, and inter-professional contact provided practical ways to improve team and individual performance. I was particularly affected by the comments of a nurse; “I realized that everything I believed in – my values, being kind to others, being benevolent – just wasn’t a reality in the hospital”. It made sad to think that clinicians who generally start their careers with such compassionate ideals can contribute to and experience these negative work experiences. I wondered if an underlying culture of kindness and respect might be the glue that holds this all together?
Hi Noel,
Thanks so much for coming along this month! I really appreciate your thoughts.
I hear what you’re saying about the gradual decay of compassionate ideals in the workplace, and agree an underlying culture of kindness and respect helps. It’s certainly what attracted me to paediatrics, things seem generally a bit kinder, but we still have plenty of conflict and divisiveness. Much to mull over.
This paper was such an interesting read and it so applicable to our medical practice. It is easy to forget that end of the day team work is the epitome of our medical profession.This will not only benefit the betterment of patient care but also to our psychological safety net which will strengthen our medical practice and behavior at work leading to the concept of work edu-tainment.
The other major highlight if this paper was the notions of the in-group and out group which often manifest in an ‘us versus them’ mentality. Indeed, Bochatay et al. 1 define conflicts as ‘social processes of disagreements between individuals and/or groups influenced by power, roles, and hierarchies’. Not surprisingly, they found that conflicts in health care often occur across hierarchical levels and professional group.
During night shifts in DEM, it is important to work collectively as team irrespective weather you are the inpatient team or the DEM team.
The margin of concept of us vs them should definitely be erased in our practice as time passes by.
As Sonia mentioned, being a supervisor for juniors there are a lot to reflect on and to practice on the floor.
Thank you for the great post.
Hi Mohan, thankyou so much for joining the journal club this month! I appreciate your comments and agree that improving inter group interactions is paramount, and I note that you mention we should erase these boundaries over time. Any thoughts on how?